Client Intake Form Where Your Journey Begins with Understanding "*" indicates required fields Intake DetailsDate* DD slash MM slash YYYY Service Required*Please select from the drop-down listCounselling ServicesCounselling Services (Incorporating Equine Assisted Therapy)Behavioural SupportEquine Services (Learn to Ride / Horsemanship)Counselling with Mens Speak OzParticipant Details (Client Utilising our Services)Name* First Name Last Name Gender Identity*Select from the drop down listMaleFemaleNon-binaryGenderqueerGenderfluidAgenderTransgenderPrefer not to sayOtherDate of Birth* DD slash MM slash YYYY Gender Identity (Other) - please provide further detailsWould you like to identify pronouns? No Yes Your Pronouns She/Her He/Him They/Them She/They He/They Other Other - Please provide detailsParticipant / Client Address* Street Address Suburb / City State Post Code Participant / Client Phone Number*Participant / Client Email Address* Important Note for NDIS Participants: These details relate specifically to the participant. Please do not use Support Coordinator email address here. If the participant does not have a unique email address, please contact the Admin Team on 4179 0730 BEFORE proceeding any further.Preferred method of communicaion* Phone SMS Email Your Funding Type* NDIS - Self Managed NDIS - Plan Managed NDIS - NDIA Managed No NDIS Support Coordination* NDIS with Support Coordination NDIS without Support Coordination Participant NDIS Number*Plan Start Date* DD slash MM slash YYYY Plan End Date* DD slash MM slash YYYY Please attach a copy of your NDIS Plan Goals and how you have nominated to achieve these. Drop files here or Select files Accepted file types: jpg, png, pdf, Max. file size: 20 MB, Max. files: 10. *Special Note - Your NDIS plan goals are essential and used to develop your Support Plan as well as your NDIS Participant Reassessment Reports for your Plan Review for continued funding.Participant Representative DetailsPlease complete this section if you have a Representative or GuardianRepresentative / Guardian Name First Last Representative / Guardian Address* Street Address City / Suburb State Post Code Representative / Guardian PhoneRepresentative / Guardian Email ** Important Information for NDIS ParticipantsOur Counselling Services including Equine Assisted Therapy are invoiced under Therapeutic Supports / Improved Daily Living Skills / Support Item Number 15_043_0128_1_3. Please discuss with us if you are unsure of your NDIS Funding Plan Allocations.Who should we send your invoices to?Name* First Name Last Name Email* Phone*Who should we send your appointments and reminders to?Name* First Name Last Name Email* Mobile Phone*This must be a mobile phone number to receive appointment reminders by SMSYour Plan Manager / Plan Nominee DetailsPlan Managers Name*Plan Managers Email* Plan Managers Phone Number*Your Support Coordinators DetailsSupport Coordinators Name*Support Coordinators Email* Support Coordinators Phone Number*Personal DetailsDo you identify as a member of the LGBTIQ+ Community No Yes Your Sexual Identity (Optional) Asexual Bisexual Gay Lesbian Pansexual Queer Straight (Heterosexual) Questioning Prefer not to say Other Other - Please provide detailsAboriginal or Torres Straight Islander Descent?* No Yes Living Situation* Own home (living alone) Own home (living with family) Living in supported accomodation Temporary (relatives, friends or other) At risk Homeless Other Do you have a current Behavioural Support Plan?* No Yes Primary Formal Diagnosis*Secondary Formal Diagnosis (if applicable)Are there any legal issues that may affect our service? If applicable, please provide all relevant details.Other relevant information that may assist our CounsellorsRepresentative or Emergency Contact DetailsContact #1* Advocate Parent Guardian Support Person Emergency Contact Plan Nominee Name (Contact #1)* First Name Last Name Relationship to Client (Contact #1)*Address (Contact #1)* Street Address Suburb / City State Post Code Phone Number (Contact #1)*Email (Contact #1)* Do you require a second Emergency Contact* No Yes Contact #2* Advocate Parent Guardian Support Person Emergency Contact Plan Nominee Name (Contact #2)* First Name Last Name Relationship to Client (Contact #2)*Address (Contact #2)* Street Address Suburb / City State Post Code Phone Number (Contact #2)*Email (Contact #2)* CommunicationType* Verbal Non-Verbal Communication aids required Other Languages Spoken* English Other Is an Interpreter required?* No Language Hearing impared Physical HealthYour GP's Name* Dr.MissMr.Mrs.Ms.Mx.Prof.Rev. Prefix First Name Last Name GP's Clinic Name*GP's Phone Number*Relevant Medical Conditions Asthma Diabetes Epilepsy Heart Conditions Visual Impairment Hearing Impairment Cognitive Impairment Blood Disorders Sleep Apnoea Any other medical conditions that we should be aware of?Medications (please list if applicable)I would like assistance managing this by:Mental HealthYour Mental Health Conditions (if applicable)* Depression Anxiety Post-traumatic stress disorder Bipolar Psychosis Schizophrenia Obsessive compulsive disorder Mood disorder Other Other, please provide relevant detailsMedications, please list if applicable:History of hospital admission* No Yes If yes, please provide further details*Practical Support NeedsI require assistance with:Mobility* Independent Assist Walking Stick Walking Frame Manual Hoist Other If other, please provide further details*The Abbwell Group can assist me by....Your PreferencesDo you have any specific preferences when matching our staff with you?Your Preferred Team Member* Andrew Abbott Gabor Kerekes No preference for Counsellor Further details about our team members can be found on the website here > Meet the TeamIs there anything you would like us to know about you that is important for how we provide our services to you?What are your goals, expectations and desired outcomes when receiving our services?What are your goals for the next 12 months?Your Initial SessionWould you like to book your Initial Session?* No Yes I will contact you shortly Booking DetailsShortly after you submit your Intake Form, you will recieve a welcome email from us with details about our Current Availability as well as how to book your initial session. You have the option to use our Automated Bookings System, or if you would like us to take care of it for you, simply contact the team in the office. Special Note for NDIS Participants: Your initial session with us will be an Induction Session where you have the opportunity to meet the team as well as complete all the required NDIS paperwork. This session is not charged to your plan. If you are booking this session from our Automated Bookings System, please choose "NDIS Participant Induction Session" from the options available. Consent and AcknowledgementDo you consent to participating in and use of:* Participating in audits of our business by the NDIS Commission and its auditors Photos for social media Photos for our website None of the above Consent* I consentI acknowledge that the information provided is true and accurate to the best of my knowledge. I understand that this information will be used for the purpose of assessing my support needs and developing a suitable support plan.
